레지던트들은 근무시간을 어떻게 사용할까? (Acad Med, 2016) (그림추가필요)

레지던트들은 근무시간을 어떻게 사용할까? (Acad Med, 2016)

How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers

Lena Mamykina, PhD, David K. Vawdrey, PhD, and George Hripcsak, MD, MS

HIT와 EHR에 대한 관심이 높아지며 이들 기술의 impact가 중요해지고 있다. 지금까지 연구로는...

With the increasing focus on the dissemination of health information technology (HIT) and the electronic health record (EHR), questions regarding the impact of these technologies on clinical practice become of paramount importance. Studies conducted thus far outline both

• 장점 the benefits of HIT and EHRs, such as

• reduction in medication errors and

• improved patient outcomes,1,2 and

• 의도하지 않은 결과 their unintended consequences, such as

• reduced efficiency,

• lower quality of care,

• increased possibility of medical errors,3,4 and

• disruptions in clinicians’ workflows, particularly if the design of the HIT or EHR does not match clinical work practices.5

HIT과 EHR의 중요성은 높아지고 있지만, 실제로 의사들이 어떻게 사용하는지는 잘 알려져있지 않다. 여러 연구에서 HIT의 사용을 정확히 구분하고 있지 않다. 그러나 EHT로 할 수 있는 일이 매우 많다.

Despite the growing importance of HIT and EHRs, the actual patterns of clinicians’ use of these technologies remain poorly understood. Many studies do not discriminate between different types of tasks clinicians perform using electronic systems or only focus on particular types of HIT, such as

• computerized provider order entry3,6,7 and

• electronic documentation.8,9

However, the rich functionality of modern EHRs suggests that a wide variety of tasks related to patient care may now be performed using computing systems.

 

레지던트 워크플로우를 연구한 결과에 따르면 직접 환자를 보는데 사용하는 시간은 매우 적고, 대부분의 시간을 educational and administrational task에 쏟는다. 이러한 현상은 수십년간 지속되어왔고, 레지던트의 시간 배분에 우려를 갖게 했다.

Previous studies of resident workflows suggested that physicians in training spend little time on direct patient care and the majority of their time on educational and administrative tasks.10,11 These observations remained consistent for several decades,12,13 leading to a standing concern about residents’ time allocation.

방법

Method

세팅

Empirical setting

We conducted this time and motion study in June and July 2010 at NewYork- Presbyterian/Columbia University Medical Center (NYP/CUMC), a large urban teaching hospital in New York, New York. NYP/CUMC had over 2,300 beds and discharged over 110,000 patients in 2009, with an average length of stay of 6.4 days.16

We conducted this study with residents (first-, second-, and third-year) on the general medicine service.

In 2004, NYP/CUMC deployed a commercial EHR system (Allscripts Sunrise, Allscripts, Chicago, Illinois). Before that, NYP/CUMC used WebCIS, which was developed in-house. The Allscripts Sunrise EHR system included a number of modules, separated into tabs (e.g., results, flowsheets, orders). Most licensed independent practitioners entered their notes directly into the EHR via a keyboard and mouse as opposed to using dictation.

연구대상

Subjects

At the time of the study, 16 residents rotated on the general medicine service (8 second- or third-year residents and 8 interns). Four (25.0%) of these residents participated in a pilot study, conducted immediately prior to the study described here. Another 7 (43.8%) participated in the final data collection study—3 (42.9%) of these participants were interns, who began their first rotations 3 to 4 weeks prior to the study, and 4 (57.1%) were second- or third-year residents.

연구설계

Study design

This study used a time and motion design to allow us to capture data on clinical activities with a high level of detail.10 During the course of the study, an experienced observer (L.M.) shadowed each participant for the 7 to 14 hours of their day shift (typically starting between 7:00 am and 8:00 am and ending between 3:00 pm and 9:00 pm). We did not include night shifts in the study. While shadowing participants, the observer captured all their activities using a custom-developed iPad application. Notably, the application allowed us to capture multiple activities simultaneously to account for multitasking (e.g., when participants were viewing a patient’s record while talking on the phone). The observer had extensive expertise with qualitative research methods, including observations of clinicians’ use of electronic documentation systems17 and clinical work practices.18

용어

Taxonomy of clinical activities

Overhage 가 개발하고 Pizziferri 가 refine한 modified taxonomy of clinical activities를 사용

For this study, we used a modified tax- onomy of clinical activities developed by Overhage et al19 and refined by Pizziferri et al,20 which we expanded to allow for a fine-grained examination of computer-based activities. The final breakdown of the computer-based activities category is given in Table 2.

데이터 분석

Data analysis

The analytic approach used in this study was inspired by the work of Zheng et al5 that described multiple analytical tools to visualize and uncover hidden regularities embedded in the sequential execution of patient care tasks in a clinical workflow. The frequencies and durations of activities were calculated using Excel (version 14.5.8 for Mac, Microsoft, Redmond, Washington).

Finally, we reviewed all field notes taken during observations and grouped them in accordance with the taxonomy based on the category of activities they referred to. We also conducted a thematic analysis of notes and transcripts from interviews. These notes, transcripts, and themes were used to provide context and explanations for data captured with the time and motion study.

Results

 

활동의 일반 패턴

General patterns of activities

The total times spent by residents on different clinical activities per shift are presented in Table 1.

다양한 활동을 동시에 하므로 개별 시간의 합은 총 시간보다 많다

Notably, because the study allowed for the capturing of different activities that happened at the same time, the total time of captured activities (1,149.4 minutes) exceeded the total observation time per shift (720.2 minutes on average) by 429.2 minutes (59.6% of shift time), suggesting that 59.6% of residents’ time was spent multitasking.

컴퓨터 기반활동

Computer-based activities

표2

Table 2 presents a more detailed breakdown of the residents’ computer- based activities per shift.

활동 시각화

Visualizing activities

Figure 2 shows a heat map visualization of the activities captured for each participant during the observed clinical shifts.

 

환자를 직접 보는 상황

As is evident from the visualization, patient interactions (black) happened mainly in three different ways:

• as part of the morning prerounding activities,

• after rounds (usually to carry out the established care plans), and

• sometimes before the end of the shift.

 

 

인턴과 레지던트의 차이: 인터뷰에서 응답자들은 higher level of skill이나 전문성이 필요한 경우가 아니라면 직접 환자를 만나는 것은 주로 인턴의 일이라고 생각했다.

The figure also shows that there was a visible difference in time spent with patients between interns and residents; the informal interviews confirmed that the participants perceived interns as being primarily responsible for direct patient contact, unless it involved procedures that required a higher level of skill or expertise.

 

컴퓨터와 종이가 모두 사용되는 시간

Both computers and paper were most commonly used

• in the morning while preparing for rounds,

• after rounds to update care plans, and

• later in the day to document changes in patients’ conditions and to check off completed to-do list items.

 

아침시간에 컴퓨터 활용은 paper와 밀접하게 연결되어 있었다. 레지던트는 회진때 볼 용도로 중요한 EHR 자료를 종이에 옮겨적는다. 그러나 오후에는 컴퓨터의 사용은 communication사이사이에 tight하게 배치되어 있었는데, 레지던트들이 다른 사람과 전화 등으로 토론을 하기 때문이다.

In the morning hours, the use of computers was tightly coupled with the use of paper. During this time, the residents copied important bits of data from the EHR onto their paper notes to have this information available for rounds. In the afternoon, however, the use of computers was tightly interspersed with communication, as residents often engaged in discussions with others in person and on the phone while using computers.

고찰

Discussion

이전 연구결과와 마찬가지로 레지던트는 전체 근무시간의 50% 이상의 시간을 컴퓨터를 쓰면서 보냈고, 직접 환자를 보는 시간은 10% 이하였다 그러나 우리가 찾은 차이는 이전 연구 (40% and 12%) 보다 더 두드러진 것이었다. 두 가지 요인을 밝혀준다.

Consistent with previous reports, our study showed that residents spend considerably more time interacting with computers (over 50% of their shift time) than in direct contact with patients (less than 10% of their shift time). The difference we found, however, was even more pronounced than what had been reported in earlier studies (e.g., 40% computer use and 12% patient care10). The study may have identified two factors that might contribute to the high level of computer use: inefficiencies in the design of the EHR system and an increasing reliance on computing systems for access to patient data. 

EHR 시스템 설계의 비효율성

Inefficiencies in the design of the EHR system

첫째, 컴퓨터 기반 활동의 대부분이 documentation과 관련된 것이었다(35%). 이는 이전 연구에 비해서도 높은 것이며 (21%), 우리 기관의 이전 보고와 비교해도 높다. 이러한 관측결과는 전자기록이 불가피하게 시간을 많이 잡아먹는 것은 아닌지 의문을 갖게 한다.

First, the study indicated that a signif- icant portion of the computer-based activities was dedicated to documentation (128.7 minutes, 35.3%). This finding is higher than similar findings in previous reports (e.g., 21% of time spent on documentation22,23), including a previous report from our institution.24 This observation raises a question about whether electronic documentation is inevitably time consuming

본 연구는 비효율적인 시간소모와 관련한 전자기록의 몇 가지 측면을 보여준다. 예컨대 레지던트는 9.3%의 시간을 note를 읽기보다는 notes의 목록을 보는데 쓴다. 이러한 상황은 레지던트가 주치의가 progress note를 "drop"하기를 기다리는 동안 발생하는 것이며, 이 "drop"하는 것은 논의된 진료계획을 실제로 수행하기에 앞서서 '공식적'으로 만들어주는 것이다. 새로운 note가 있을 때 EHR이 레지던트에게 알림을 주지 않기 때문에 정기적으로 업데이트가 있는지 확인해야 한다. 또한 patient record의 분절이 있어서, patient data catetory에 여섯 개의 분절된 item들이 있고 레지던트들은 상당한 시간을 이 서로 다른 영역들로부터 자료를 통합하는 작업에 사용해야 한다. 마지막으로 데스크탑 컴퓨터에 의존하는 방식과 환자에게 떨어져있는 위치는 레지던트가 환자를 직접 보면서 컴퓨터기반활동을 통합하는 것을 더욱 어렵게 한다.

This study may have highlighted several aspects of electronic documentation that contributed to inefficient use of time spent documenting. For example, residents spent 33.9 minutes (9.3%) of their shift time viewing the list of available notes rather than reading them. Our field notes suggested that these situations often occurred when residents were waiting for an attending physician to “drop” their progress note, which would make the discussed care plan official, before proceeding with the planned activities. Because the EHR did not alert the residents to newly posted notes, they had to periodically look for updates. In addition, the high degree of fragmentation in the organization of the patient record, reflected in the six distinct items within the looking-up-patient- data category (which corresponded to six different areas of the EHR containing patient data), may have required residents to spend a considerable amount of time consolidating data from these different areas. Finally, the reliance on desktop computers and their positioning away from patients made it impossible for clinicians to integrate computer-based activities with more direct patient care activities.

 

환자 자료 접근을 위한 컴퓨터 시스템에 의존 증가

Increasing reliance on computing systems for access to patient data

레지던터의 컴퓨터 기반 활동의 약 절반가량은 documentation과 관련된 활동이 아니라 환자자료를 열어보는 것 등등에 사용되었다.

Second, the study suggested that half of residents’ computer-based activities time was spent on activities not related to documentation but, rather, to

• reviewing patient data (looking up patient data, 70.8 minutes [19.4%]);

• managing and coordinating patient care (managing orders, 48.1 minutes [13.2%], and

• communicating, 9.6 minutes [2.6%]); and

• other activities (other, 24.0 minutes, [6.6%]).

 

이러한 결과는 patient care의 delivery는 오더와 to-do list의 잦은 업데이트를 필요로 함을 시사하며, 그래야 patient care team이 각자의 역할을 효과적이고 효율적으로 할 수 있기 때문이다. 더 나아가서 비공식 인터뷰에서 레지던트들은 신장내과와 같은 분과 로테이션을 경험한 경우 환자 접촉에 덜 의존하고 EHR에 저장된 정보에 더 의존한다고 응답하였다. 컴퓨터 시스템을 통해서만 접근할 수 있는 환자 자료의 양이 많아지고 풍부해질수록 이러한 경향은 더 심해질 것이다 그렇다면 문제는 이러한 자료를 해석하는데 환자의 역할이 필요하다고 한다면, 컴퓨팅 시스템이 환자와 의사간의 engagement를 diminish하기보단 facilitate하는 방법을 찾는 것이다.

These findings suggest that delivery of patient care necessitates frequent updates to orders and to-do lists to allow members of patient care teams to carry out their respective responsibilities in an efficient and effective manner. Moreover, during the informal interviews, residents who previously completed specialty rotations, such as nephrology, reported decreased reliance on patient contact and increased reliance on information stored within the EHRs (e.g., the available laboratory test results). With the growing amount and richness of patient data available only through computing systems, these trends are likely to amplify. Questions remain, however, as to the role of patients in helping clinicians to interpret these data and ways in which computing systems can help facilitate engagement between patients and clinicians, rather than diminish it.

Study limitations

 

결론

Conclusions

이미 의료행위는 컴퓨터 의존에 있어서 "돌아올 수 없는 강"을 건넜다. 그렇다면 의사가 이것을 이용해야 하는가 마는가, 얼마나 이용해야 하는가가 문제가 아니라, 무엇을 위해 사용하고, 어떤 정도로 컴퓨팅 시스템이 진료행위를 support할 수 있는지 아는 것이다.

Arguably, the practice of medicine may have reached the “point of no return” in regard to its reliance on computing systems. The question then becomes not whether and how much clinicians should use computers, but what they should use them for and to what degree the use of computing systems can support clinical care activities.

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Acad Med. 2016 Jun;91(6):827-32. doi: 10.1097/ACM.0000000000001148.

How Do Residents Spend Their Shift Time? A Time and Motion Study With a Particular Focus on the Use of Computers.

Mamykina L1, Vawdrey DK, Hripcsak G.

Author information

• 1L. Mamykina is assistant professor of biomedical informatics, Department of Biomedical Informatics, Columbia University, New York, New York. D.K. Vawdrey is assistant professor of clinical biomedical informatics, Department of Biomedical Informatics, Columbia University, and vice president, Value Institute, NewYork-Presbyterian Hospital, New York, New York. G. Hripcsak is chair, Department of Biomedical Informatics, Vivian Beaumont Allen Professor of Biomedical Informatics, Columbia University, and director, Medical Informatics Services, NewYork-Presbyterian/Columbia University Medical Center, New York, New York.

Abstract

PURPOSE:

To understand how much time residents spend using computers compared with other activities, and what residents use computers for.

METHOD:

This time and motion study was conducted in June and July 2010 at NewYork-Presbyterian/Columbia University Medical Center with seven residents (first-, second-, and third-year) on the general medicine service. An experienced observer shadowed residents during a single day shift, captured all their activities using an iPad application, and took field notes. The activities were captured using a validated taxonomy of clinical activities, expanded to describe computer-based activities with a greater level of detail.

RESULTS:

Residents spent 364.5 minutes (50.6%) of their shift time using computers, compared with 67.8 minutes (9.4%) interacting with patients. In addition, they spent 292.3 minutes (40.6%) talking with others in person, 186.0 minutes (25.8%) handling paper notes, 79.7 minutes (11.1%) in rounds, 80.0 minutes (11.1%) walking or waiting, and 54.0 minutes (7.5%) talking on the phone. Residents spent 685 minutes (59.6%) multitasking. Computer-based documentation activities amounted to 189.9 minutes (52.1%) of all computer-based activities time, with 128.7 minutes (35.3%) spent writing notes and 27.3 minutes (7.5%) reading notes composed by others.

CONCLUSIONS:

The study showed that residents spent considerably more time interacting with computers (over 50% of their shifttime) than in direct contact with patients (less than 10% of their shift time). Some of this may be due to an increasing reliance on computing systems for access to patient data, further exacerbated by inefficiencies in the design of the electronic health record.

PMID:

 

27028026

 

PMCID:

 

PMC4879085

 [Available on 2017-06-01]

 

DOI:

 

10.1097/ACM.0000000000001148

[PubMed - in process]